Diagnosis: Infection of Finger.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a history of intravenous drug use who presented to the emergency department (ED) with cellulitis of the right ring finger with purulent drainage from the finger. She was diagnosed with a paronychia. Drainage of the paronychia was attempted in the emergency department (ED) but with no return of pus. She was admitted for intravenous (IV) antibiotics. She developed drug withdrawal and was treated for her symptoms. The patient self-discharged. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. The patient had a finger infection and was admitted for IV antibiotics. According to Milliman Care Guidelines (MCG) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations." This patient was medically stable and needed only IV antibiotics and management of her withdrawal symptoms. She could have been safely managed at a lower level of care than inpatient. Had she failed to respond to IV antibiotics, she could have been admitted but she left the hospital.